Hypertension

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Hypertension

• Howard L. Sacher, D.O.
• Long Island Cardiology and Internal Medicine

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Learning Objectives

• To know how to detect and diagnose hypertension
  and its secondary causes.
• To become familiar with updated recommendations
  for classifying hypertensive patients.
• To understand the pharmacologic options for
  treating hypertension and their appropriate use.
• To grasp the importance of counseling patients on
  lifestyle modification to help control
  hypertension

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Hypertension

• Hypertension is the most well established and
  important risk factor for
• 1 Cardiovascular disease
• 2 Cerebrovascular events
• 3 Congestive Heart Failure (CHF)
• 4 End stage renal disease (ESRD)

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Hypertension (cont)

• There have been enormous advances in our
  understanding of the value of treating
  hypertension over the past three decades, yet the
  most recent surveys show that hypertension
  remains largely untreated and uncontrolled

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Hypertension (cont)

• The relationship between systolic and diastolic
  blood pressure is strong, graded and continuous
• The higher the BP, the higher the risk
• Systolic BP is a better predictor of
  cardiovascular disease at all ages but
  particularly in the older age group
• Diastolic BP does not rise with age after the
  fifth decade, a time when isolated systolic BP
  begins to increase sharply in prevalence

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Patient Evaluation

• Repeat BPs
• Teach Patients to take BPs
• Promotes participation by patient
• May reduce costs by reducing visits
• Ambulatory BP monitoring
• BP
• Evaluate diurnal variations
• Patient at a greater risk for end organ disease

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Patient Evaluation (cont)

• History medication , lifestyle habits such as
  diet, exercise, smoking history, family history
  and review of symptoms that may reflect secondary
  hypertension, target organ disease or co-morbid
  conditions

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Patient Evaluation (cont)

• Physical Exam
• BP standing and sitting in both arms and legs
• Looking for patients with orthostatic hypotension
  over 60
• Coarctation of the aorta in younger patients
• Peripheral vascular disease
• Fundoscopic exam looking for evidence of
  hypertensive retinopathy

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Patient Evaluation (cont)

• Evaluation of the Heart
• S4 decreased LV function compliance precedes
  systolic dysfunction or S3 gallop
• Evidence of CHF
• Rales (Crackles)
• Hepatomegaly
• Peripheral Edema
• Neurological exam for evidence of Cerebrovascular
  disease

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Patient Evaluation (cont)

• Laboratory Evidence
• Complete blood count (CBC)
• Renal failure and polycythemia
• Chemistries Na, K, creatinine, fasting
  glucose and lipid profile
• K - low in hyperaldosteronism, high in renal
  failure
• Urinalysis
• 12 lead EKG
• LVH, Ischemia

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Pheochromocytoma

• Pheochromocytoma
• Catacholamine producing tumors can occur in the
  adrenal gland or anywhere along the
  neuroectodermal crest 10 of adults have
  multiple tumors
• Triad
• Episodic Headaches
• Tachycardia
• Diaphoresis with labile hypertension
• Associated with multiple endocrine neoplastic
  (MEN) syndromes, neurofibromatosis, and Van
  Hipple Landau syndrome

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Pheochromocytoma

• Diagnosis
• Postural hypertension
• Resting tachycardia
• Café au lait spots
• Resting supine catacholamine levels gt 2000 pg/ml
  (nep, ep)
• Clonidine suppression test
• Lowers catacholamine levels in essential HTN but
  not pheochromocytoma
• Glucagon (2mg IV) increases plasma catecholamines
  at least three fold or gt2000 1 to 3 minutes after
  administration in patients with pheochromocytoma

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Pheochromocytoma

• Tumor Localization accomplished by
• CT scan
• MRI
• Radioisotope uptake studies
• Treatment
• Surgical removal of tumor
• Alpha and beta adrenergic blockers are useful for
  chronic management or non-surgical cases (alpha
  blockers commonly used)

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Hyperaldosteronism

1. Spontaneous hypokalemia while on diuretics and
   potassium supplements
2. Primary Hyperaldosteronism
3. Small unilateral adenoma (lt1cm) is more common
   in women
4. Bilateral adrenal hyperplasia is more common in
   men
5. Diagnosis
6. Measure 24 hour urinary aldosterone measurements
   for two days on high sodium diet (gt!4g/ 24 hours)
7. Increased aldosterone with low levels of plasma
   renin activity
8. Adenomas detected by MRI

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Hyperaldosteronism (cont)

• Treatment
• Surgery for small solitary adenomas
• Medical treatment for adrenal hyperplasia
• Diuretics and vasodilators
• Aldosterone antagonists do not reduce BP
  adequately but may be needed to correct
  hypokalemia

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Renal Artery Stenosis

• More commonly found stage 3 or resistant
  hypertension
• When bilateral can have reduced kidney function
• Clinical clues to renovascular disease
• Onset before age 30 or recent onset of
  significant high BP after age 55
• Abdominal bruit if diastolic and lateralized
• Accelerated or resistant high blood pressure
• Recurrent flash pulmonary edema
• Renal failure with normal sediment
• Co-exiting ASVD especially in long smokers
• Acute renal failure particularly after ACE I or
  Angiotensin receptors blockers

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Renal Artery Stenosis (cont)

• Diagnosis
• Captopril enhances radionuclide renal scan
• Duplex doppler flow studies
• MRI and MRA
• Definitive diagnosis angiography
• Treatment
• Revascularization
• Fibromuscular dysplasia Percutaneous
  transluminal renal angioplasty (PTRA) is
  comparable to surgery
• Atherosclerotic renal artery stenosis ideal for
  PTCA with stenting if renal function normal
• Surgery or PTCA with stenting to preserve renal
  function

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• LVH with left atrial enlargement

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• HTN 2nd to RAS

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• HTN 2nd to Fibromuscular Dysplasia

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10-Minute Break
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JNC - VI

• Joint National Committee (JNC) on the Detection,
  Evaluation and Control of High Blood Pressure
• Emphasis risk stratification for cardiovascular
  disease
• Smoking
• Dyslipidemia
• Diabetes Mellitus
• Old age
• Male sex
• Post-Menopausal
• Family History of cardiovascular disease

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At any given level of SBP the absolute risk of a
coronary event increases dramatically as compared
to those with no risks
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Classifying patients with HTN with consideration
to target end organ damage/clinical
cardiovascular disease (TOD/CCD)
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Lifestyle Modifications

• Weight redistribution lowers BP but also has
  effect on lipids and glucose metabolism
• There is a Metabolic Syndrome
• Obesity
• High BP
• Hyperlipidemia
• Insulin resistance or Diabetes
• Reduction of dietary sodium
• Correlation between dietary sodium and blood
  pressure most patients benefit from reducing
  intake to below 2400mg/day, 6 g salt. Also
  enhances the efficacy of anti-hypertensive agents
  and may reduce potassium effect of diuretic
  agents and minimize hypokalemia. (i.e. processed
  foods)

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Lifestyle Modifications (cont)

• Alcohol
• 1 ounce of ethanol
• 24 ounces of beer
• 10 ounces of wine
• 2 ounce of 100 proof whisky
• Tobacco
• Aerobic Exercise

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Diabetic Hypertensive patients

• Blood glucose controlled
• Weight loss
• Aerobic exercise
• Angiotensin Converting Enzyme (ACE) Inhibitors or
  Angiotensis Receptor Blockers (ARB)
• Treatment to lower BP using ACE-I and ARB
• Microvascular retinopathy, nephropathy
• Macrovascular CAD, angina, AAA, CVA
• BP goals lt or to 120 / 80

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Congestive Heart Failure

• Treatment
• ACE I
• ARB
• Diuretics
• B-Blockers
• Digitalis
• Monitor for
• Orthostatic hypotension
• Renal function
• K levels

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Post-Myocardial Infarction

• Treatment
• ß-Blockers
• ACE- I in patients with systolic dysfunction
• Diltiazem or Verapamil in patients with non
  Q-wave infarction may be used if B-blocker
  ineffective or contraindicated

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Isolated Systolic Hypertension (ISH) and
Hypertension in older patients

• Higher risk for cardiovascular disease
• Lifestyle modifications
• Decreased vascular compliance due to loss of
  arterial elasticity associated with aging
• Drug of choice
• Low dose thiazide diuretics
• Be concerned about postural hypotension or
  cognitive dysfunction (central alpha 2 agonists)

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Ischemic Heart Disease

• Treatment
• B-Blockers
• Calcium channel blockers as a second choice if
  beta blockers are contraindicated or both drugs
  can be used together to achieve BP goals
• Treat risk factors
• High lipids
• Diabetes or Insulin resistance
• Weight loss
• ACE-Inhibitors

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Renal Disease

• Aggressive treatment to lower BP
• lt or 130/85
• Goal will slow rate of disease progression
• ACE inhibitors are drugs of choice but must be
  used with caution if creatinine gt3 mg/dl and are
  not used when renovascular hypertension is
  suspected
• Thiazide diuretics are not effective if serum
  creatinine is gt 2.5 mg/dl and loop diuretics are
  required

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African-Americans and HTN

1. High prevalence
2. Occurs earlier, more severe and is associated
   with higher risks of cardiovascular disease
3. Stroke and heart disease mortality rates 80 and
   50 higher respectively
4. End stage renal disease 320 higher
5. Lifestyle modifications
6. Diuretics are drugs of choice for uncomplicated
   hypertension
7. Ca channel blockers and alpha blockers are also
   effective
8. All other drugs can be used to achieve BP goals

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Women and HTN

• Same therapy as men
• If on OCP stop and monitor BP
• During pregnancy ACE-I and ARB should be stopped
• Alpha-Methyldopa during pregnancy

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Patients Undergoing Surgery

• If BP is gt 180/110, patient must be treated to
  reduce the risk of perioperative ischemic events
• Cardio-selective beta-blockers, unless
  contraindicated, are drugs of choice
• Hypertensive patients who are well controlled
  prior to surgery should be continued on their own
  regimen as soon as possible after surgery

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Meta-analysis on the various first line drug
treatments
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BP gt 95th percentile is considered elevated in
children
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Hypertensive Emergencies

• Reduce mean arterial pressure (MAP) no more than
  25 (minutes to several hours) and then to
  160/100 mmHg avoiding excessively rapid falls
  that may precipitate cerebral or coronary
  ischemia
• Sublingual nifedipine is not recommended because
  of the relatively high risk for these adverse
  events

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Patient Education and Lifestyle modifications

• Lose excess weight.
• Cut the fat.
• Limit alcohol intake.
• Exercise regularly.
• Reduce sodium intake.
• Stop smoking.

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Follow-up

• Once stable, patients should be re-evaluated at
  least every 3 to 6 months
• Review compliance, effectiveness and adverse
  reactions
• Quality of life issues should be considered,
  including sexual function
• At least annual evaluation of urinalysis,
  creatinine and potassium are appropriate,
  generally as part of a screening laboratory panel